Nokea
Select the hazard of immobility that is accurately paired with an appropriate expected outcome of care that the nurse provides to prevent this complication.
- A. Bone demineralization: Turning and positioning every 2 hours
- B. Urinary stasis: The client will consume 1,000 mL of oral fluids per day
- C. Muscle atrophy: The client will perform range of motion exercises at least 3 times a day
- D. Hypercalcemia: Maintaining fluid intake of 1,000 mL per day
Correct Answer: C
Rationale: Range of motion exercises prevent muscle atrophy by maintaining muscle strength and function in immobile clients.
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A client with severe major depression states, 'My heart has stopped and my blood is black ash.' The nurse interprets this statement to be evidence of which of the following?
- A. Hallucination.
- B. Illusion.
- C. Delusion.
- D. Paranoia.
Correct Answer: C
Rationale: The client's statement reflects a false, fixed belief that is not based in reality, which is characteristic of a delusion. Hallucinations involve sensory perceptions, illusions are misinterpretations of stimuli, and paranoia involves suspicion, none of which fit this scenario.
You are the registered nurse in a multi ethnic community health department clinic. In this role you are asked to identify clients who have genetic risk factors related to ethnicity in order to screen them for some commonly occurring diseases and disorders. You would identify a client who is of:
- A. Mediterranean ethnicity for cystic fibrosis.
- B. African American ethnicity for Tay Sachs disease.
- C. British Isles ethnicity for psychiatric mental health disorders.
- D. Saudi Arabian ethnicity for sickle cell anemia.
Correct Answer: D
Rationale: Sickle cell anemia is strongly associated with populations from regions like Saudi Arabia, Africa, and parts of India. Screening clients of Saudi Arabian ethnicity for sickle cell anemia is appropriate due to the higher prevalence of the sickle cell trait in these populations.
The mother of a newborn is concerned about the number of persons with heart disease in her family. She asks the nurse when she should start her baby on a low fat, low cholesterol diet to lower the risk of heart disease, the nurse should tell her to start diet modifications:
- A. At birth.
- B. At age 2.
- C. At age 5.
- D. At age 10.
Correct Answer: B
Rationale: Diet modifications for heart disease prevention, such as low-fat, low-cholesterol diets, are generally recommended to begin at age 2, when children transition to a more varied diet.
A child with partial- and full-thickness burns is admitted to the pediatric unit. Which of the following should be the priority at this time?
- A. Preventing wound infection.
- B. Evaluating vital signs frequently.
- C. Maintaining fluid and electrolyte balance.
- D. Managing the child's pain.
Correct Answer: C
Rationale: Maintaining fluid and electrolyte balance is the priority in burn care to prevent hypovolemic shock due to significant fluid loss.
A 5-year-old child is admitted with a fever and rash. The nurse suspects scarlet fever. Which assessment finding supports this diagnosis?
- A. Strawberry tongue
- B. Koplik spots
- C. Vesicular rash
- D. Pustules on the trunk
Correct Answer: A
Rationale: Strawberry tongue is a characteristic sign of scarlet fever, caused by group A Streptococcus, aiding in diagnosis confirmation.